Wednesday, October 21, 2009

Medicine is a business. Believe me, as a doc in solo practice I REALLY understand that. I want to help people, but also have to pay Mary & Annie, and my mortgage, and Diet Coke bills, and office rent, etc.

In a perfect world, healthcare would be free and unlimited. But our world isn't perfect, and the issue becomes balancing finite dollars against virtually infinite need.

We all try to do our best (I hope) to care for patients within our means.

3. Futile care is often given, usually due to family members feeling guilty. All of us in this business have seen a 90+ year old person with advanced dementia and other serious medical issues, being kept alive with machinery at a family's insistence.

4. Unnecessary admissions for bullshit reasons are common, and a huge waste of resources. My esteemed colleague ERP recently wrote an excellent post on this over at WhiteCoat's Call Room.

5. In my career I've known some system-abusing nurse managers. For example: Years ago I worked at a hospital where one floor's nurse:patient ratio was supposed to be 1:4. Instead, it was often 1:5 or 1:6. This lowered quality of care and increased nurse burn-out, and most docs sure noticed it (I don't go to that hospital anymore).

At a meeting to address these concerns the floor manager was asked why this problem kept occurring. She explained to us that her year-end bonus was based on how far under-budget the floor was, and that she needed to run the floor understaffed because she was trying to afford a down payment on a new car.

6. Some insurance companies have policies where doctors are paid a bonus based on how much care they DON'T do (I don't participate in those contracts). In other words. Big Insurance, Inc., says to Dr. X. "Here is $100,000 (hypothetical number) to pay for all our patients' tests this year. If you only spend $75,000, then you get to keep the other $25,000."

This is grossly unfair. In a perfect world the doctor would ignore this. But it ain't perfect, and we all have bills and families, and so it puts the doc in a difficult situation. And of course, if he doesn't do a test and gets sued, who gets nailed? Not Big Insurance, Inc.

These contracts, fortunately, are in rapid decline. They were most popular during the 90's. But are dying now as more and more docs refuse to accept them.

7. Pay-for-performance (also called P4P). This has been kicked around in the last few years. The idea is simple. Docs who have good patient outcomes will get paid more. After all, shouldn't they be rewarded for being better docs?

The problem here is that some conditions are basically untreatable. And some patients don't care about their own health. If something like this happened, WTF would I want to see someone with something incurable, like Alzheimer's disease? I'd only want to see simple stuff with generally good outcomes, like a young, healthy patient with carpal tunnel syndrome or occasional migraines.

If you've had a stroke, or brain cancer, or something else that ain't so good, then good luck finding a doc who's going to take you on with P4P. Because sick people are only going to cut doctor reimbursements since their outcomes will be worse. And, like I said, in a perfect world docs wouldn't look at the bottom line. But in this world we all have bills and families.

Not only that, but if I beg Mr. Marlboro to quit smoking, and he doesn't, and has a stroke, then I get penalized for a poor outcome that was out of my control.

For P4P to work, it's going to need A LOT of tinkering.

8. And my last whine, and the one that got me thinking to write this:

I got called to ER early yesterday morning to give an older gentleman TPA, the clot-busting drug. He had right-sided weakness, but fortunately got better on his own. Later in the morning, however, he worsened again, then got better again, and kept fluctuating. I kept running back & forth between my office and the hospital as the situation changed. I finally got him stabilized with medications, and ordered a bunch of tests (MRI, MRA, echocardiogram).

About 6 hours after I left the floor, I got called by Dr. Hungry Hospitalist.

Dr. Hungry: "Yeah, this stroke guy. Can I send him home now?"

Dr. Grumpy: "He hasn't had any of his tests yet, has he?"

Dr. Hungry: "No. Can't you just do them as an outpatient?"

Dr. Grumpy: "I'm not comfortable with that. He needs a work-up. His last TIA was only 6 hours ago, and I'm not even sure he's neurologically stable at this point. It's too soon to see."

Dr. Hungry: "I'm sure he's stable. Can't you just see him in your office in a few days?"

Dr. Grumpy: "Why are you so eager to toss him,?"

Dr. Hungry: "Um, well, uh, my, um, year-end bonus is based on how short I'm able to keep my average patient length of stay, and I had a really sick lady a few months ago who was here forever, and blew my average to hell, so I really need to bring it down because I've got a med school loan lump sum payment due in January and..."

Too many patients now are coming to the hospital, when they are critical. And yet Dr Hungry, is too involved in his own financial problems. Sorry Dr G., this guy should not be practicing medicine. Esp ICU patients. Or really any patients. Why call You on consult, if he's is obviously going to do what he chooses. Did he really discharge that patient? I hope not. These are tests that are necessary for the patient, hopefully to GET BETTER. I shouldn't matter , the age of the patient either. How would that Dr like if a family member of his were treated that way? Dr Hungry ..go into another field, if this is how you are going to treat people. We as a healthcare community don't want your kind taking care of us, or friends and family,. In other words..TAKE A HIKE!!!!!!!!!!!!!!!!!!!

P4P doesn't have very accurate methods of accounting for disease severity. So if there are 2 TIA patients, and one of them is simple, the primary care doc works that one up, and has the good outcome with low expenditure. The other one gets referred to a neurologist, who right away is doomed to demonstrate worse outcomes - he/she is starting out with sicker patients. Similarly, P4P will undermine our major medical centers, where the most complex patients get refered - the only way for a hospital system to survive will be to specialize in caring for patients that aren't sick.

And we wonder why all the cynicism when it comes to Doctors. By what you've just chronicled, I'm appalled, but not shocked. Several in my immediate family either an OB Dr, RN, Dpt head of Nursing, ER Nursing managers pharmacist, or a physical therapist, so these sort of stories are regular topics of discussion. The consistent theme of which always involves someone or some company trying to make money.

I get the impression that one time a few of these programs worked, but only because patient's needs were actually a real consideration and the medical community could be trusted to adhere to that. Not so anymore. I hear a lot of mention of younger doctors getting into medicine for the wrong reasons. Don't know if that plays into this or not from your perspective.

In any case, I'm not a big government guy, but it seems more and more that because people can not regulate their behavior, the feds have to step in. With murders and rapists, it's obvious that we need laws to protect citizens, but with white collar greed more and more prevalent the government is almost compelled to act to protect citizens. The problem, however, (and this is my opinion) is that in the latter scenario the issues and ramification are more convoluted and ambiguous. Thus, a policy to regulate one aspect of healthcare has unforeseen consequences impacting (often negatively) another related area. Plus, throw the lobbyists represented drug and insurance companies and these policies can be tainted from the start.

I may be way off base, and that's fine because I willing admit to this is just an opinion built off of my impression of what I've seen so far.

This is really off-topic, but have any patients ever given you a gift basket or something after treating them for a full year (seeing them every week for therapy or some checkup)?

I'm contemplating sending something to my doctor as a thank you gift but I don't know if this is frowned upon or if it's awkward. What kind of stuff do patients usually send doctors besides fruit baskets? Thanks!

Thankfully I am a med-student in the UK and I've gotta be honest it's nice to work in a system that doesn't dance to the tune of penny pinching insurance companies! I don't envy you having to work like that at all.

On an aside, a few of my colleagues and I really enjoy reading your blog - it reassures us that the consultants aren't just palming off the stupid patients on us!!

House has had some really shady business deal stuff happen. Remember season 2, with the bicyclist who collapsed during a race? His manager offered Cuddy X amount of dollars and magically her cyclist got his test. Remember te s4 episode with House being pushed around by the megalomaniac that was runnin the hospital because he had deep pockets? (Either house puts on a white coat or my funding is GONE).

It's sad... we all know that. The question is, how the hell do we fix it...

Grumpy, if that idiot is basing medical recommendations to limit care on his bottom line, he is committing malpractice. Punting a critical case out of the hospital just to pad the pockets is dangerous. It goes beyond the normal greed I see with extra testing to bump up the bill. At least with that, you are not really endangering the patient.

I am a vet and paid on production. While this can allow greedy people to increase their income based on needless testing and treatments, I at least get paid for busting my ass (like the 6 poly-traumas that were triaged to the back within 10 minutes of each other last night).

#5 has happened at our hospital. We were very thankful for the doctors who helped get it straightened out. As it played out, we were told (threatened) to quit sharing information with the doctors, but good triumphed over evil (for now...).

I get asked a lot if I have a solution to the medical care problem. I don't.

There are so many varibles, it's impossible to work out a solution that's equitable. Or at least, beyond my scope.

I do wish the politicians would realize that this is a much trickier issue than they think it is, and spend just a little more time thinking about it, before they just ram some cobbled-together, piecemeal compromise down everyone's throats.

Medical care is a commodity. We can't just fiat for everyone to have gold standard health care. It would be great, but those dollars have to come from SOMEWHERE.

Dr. Grumpy, I think you should have an ongoing poll in your blog sidebar. At the beginning of each week, pull the four biggest jackasses and have your readers vote as to which one was most vile. Then at the end of the month vote on who wins the Jackass of the Month award, and post the results in the sidebar all month for everyone to see.

What a very depressing post! Thanks for reminding me why I left healthcare.

I saw many doc contracts with bonuses and never thought it made sense. My favorites are the physician report cards with the comparative volume and ALOS stats. As though the docs had control over the severity of illness of their respective patients. Again, thanks for reminding me why I left healthcare.

After all the years I dealt with Medicare and Medicaid and their annual audits 7 plus years late I don't think they have a clue how to fix healthcare.

I'm not going to defend Dr. Hungry, but he is exhibiting perfectly normal and predictable human behavior in this situation. The basic problem is a system in which he is paid more for doing less. Can you think of any other profession in which this would even be considered?

This is why I have always felt that payment systems like capitation and the one in this incident are fundamentally and unchangably unethical.

So, Dr. Grumpy, thank you for this post....I just began Medical Assistant schooling and I am currently taking a class about medical office prodecure....we've been discussing all of the things it takes to run an medical practice...this blog post will be an excellent 'show and tell' in class on friday, as our teacher has been trying to educate us on how complicated things can be when trying to run a practice and be ethical and still make a living.

Wow, that's really disturbing. I tend to be somewhat idealistic in my expectation of how fellow professionals behave with respect to ethics, morals, doing the right thing... I'm really upset to hear about this.

This is my first time commenting, and I want to start by saying I LOVE your blog. You're absolutely hilarious. I'm a long time reader and have never commented before, but I felt compelled to comment now because of #5 on your list. My mother is a nurse manager and works at a hospital where there is no pay incentive to do such a thing, and even if there were I know she would never do that. While I don't disagree that there are some unethical nurse managers who do that, I would argue that the majority of them are forced to do it because they are understaffed and have no choice.

First off, I don't live in the States but in Germany so I am used to a very different health care system. And I sincerely hope I will never have to worry about having health insurance. I have never been in the position where I actually depended on a doctor for my life yet but many people have.I think the system in the States as it is is really bad. Too many people are without insurance, too many people delay doctor's visits until they are really really really sick because they don't want to fork out the money until they absolutely have to (and then their treatment is much more expensive).I also think that probably doctors are too interested in money. Of course doctors do great work (well, unless they're bad doctors), but I also think that the job of a doctor is not comparable to any other job and I think people know that (or should know that) when they sign up for it. Someone on another blog (a doctor) said basically that no one else would work without getting paid (normal office jobs for example), but I do think doctors have the moral obligation to help sick people and they know that (hello, Hypocratic oath). Their job often decides between life and death. Most people can't say that about their jobs. Of course they should get paid for it, but I don't think that's even up for debate anyway.I also think it's a problem that doctors in the US start out with (hundreds of) thousands of debt due to medical school, another problem doctors here don't have. Money just matters too much right from the start. For everyone involved in this thing that is the healthcare system (patients, doctors, insurance companies). I cannot even imagine being in the position you described where you actually have to call an insurance company to ask whether a necessary treatment will be covered! Here, for public health insurance companies, we have a catalog of treatments that are always covered if medically indicated (the decision lies with the doctor). So if my doctor decided I needed an MRI for something, my insurance would pay, no questions asked. I would never even see a bill nor would the insurance be informed of my treatment until they get billed for it.I just started allergen immunotherapy which is probably the most expensive medical procedure I am undergoing in my entire life so far (well, in the long run), and all I pay is a copay of $15 on a $500 prescription (and I get two of those every 3-4 months for three years). This is a treatment generally covered by public health insurance so my doctor prescribed it and of course he did not have to ask my insurance about it. (This is in response to that post you wrote a while back about having to ask insurance companies for 'permission', I cannot believe the amount of time wasted on that by doctors and insurance companies day-in-day-out.)This comment is a little all over the place, so I hope you can make sense of it anyway.

Wow, Dr.G could you get booked for a few days on the senate floor and try to relay some of your insights to the men in power. I worked at one of the original HMO's in California and this kinda of "payment/bonus" plan just kills me. I understand the docs needs for cash but just where does fall in the hypocratic oath he agreed to?

I'm starting to feel there are two kinds of doctors in our country:1. Those whom the system has defeated and who, to survive, have to resort to all these games to keep up, let alone stay ahead.2. Those who are saying "I'm outta here" and are looking for other more sane ways to make a difference and a living!I know I belong to the latter.Have I missed any other kind?

If doctors get more money for not ordering stuff on patients in the 1990's and that kind of care is bastard care, how about fee for service care were the neurologist only has to "order two EEG's a day to pay for my overhead".

As one neurologist once told me.

Fee for service that results in unnecessary care just as bad and that care is rampant.

Even the neurologist has a car payment every now and then.

By the way, any payment model that links length of stay to compensation is illegal. I doubt event the hospitalist knows what they were talking about.

I never consult neurologists for TIAs. I find their care expensive and rarely helpful on most occasions. That's not to say they don't have something to offer every now and then. Just not that often

>>And many get into it to help people, and between student loans and family and life discover that it's not the financially solvent field it used to be, and then do anything desperately to make a buck.>>

His arrogance is inexcusable. Better outcomes are associated, in general, with greater training and experience. Outcome in stroke across medical specialties is well-studied. See Neurology. 1998 v50(6):1669-78. The finding: "Evaluation by a neurologist is associated with better survival for most patients ..."

Arrogance? Nice. My comments are based on my 10 years of experience in working with neurologists in my community. In fact most neurologists have no interest in taking care of TIAs. To be dragged away from their office to "see another TIA". Why just the other day, I talked with a neurologist whom the ED had consulted for possible "stroke alert". When the ED determined they weren't a TPA candidate, we were asked to admit. I called the neurologist after my evaluation and told them I have it under control and they don't have to see. They said thanks.

Exactly what do you think internists are capable of managing independently if not TIA? Honest question, since the thought of an internist not being able to manage TIA independently is rather hilarious.

I take care of just about everything in the hospital everyday, in one way or another without subspecialty assistance. And my complication rates are 1/3 of the expected severity adjusted rates. My mortality rate is 1/2. And I save almost $2,000 per discharge compared to other internists.

You can call me arrogant. I call it excellent care. And I have the data to back it up.

Welcome to my whining!

This blog is entirely for entertainment purposes. All posts about patients may be fictional, or be my experience, or were submitted by a reader, or any combination of the above. Factual statements may or may not be accurate.

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